National Academies Press: OpenBook
Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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FUTURE OF EMERGENCY CARE

HOSPITAL-BASED EMERGENCY CARE

AT THE BREAKING POINT

Committee on the Future of Emergency Care in the United States Health System

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

THE NATIONAL ACADEMIES PRESS

500 Fifth Street, N.W. Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract No. 282-99-0045 between the National Academy of Sciences and the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ); Contract No. B03-06 between the National Academy of Sciences and the Josiah Macy, Jr. Foundation; and Contract No. HHSH25056047 between the National Academy of Sciences and the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC), and the U.S. Department of Transportation’s National Highway Traffic Safety Administration (NHTSA). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

Library of Congress Cataloging-in-Publication Data

Hospital-based emergency care : at the breaking point / Committee on the Future of Emergency Care in the United States Health System, Board on Health Care Services.

p. ; cm. — (Future of emergency care series)

Includes bibliographical references and index.

ISBN-13: 978-0-309-10173-8 (hardback)

ISBN-10: 0-309-10173-5 (hardback)

1. Hospitals—Emergency services. 2. Emergency medical services. I. Institute of Medicine (U.S.). Committee on the Future of Emergency Care in the United States Health System. II. Series.

[DNLM: 1. Emergency Service, Hospital—United States. 2. Health Care Reform—United States. WX 215 H8261 2007]

RA975.5.E5H67723 2007

362.11—dc22

2007000079

Additional copies of this report are available from the

National Academies Press,

500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.

For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2007 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine


The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.


The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering.


The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.


The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council.


www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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COMMITTEE ON THE FUTURE OF EMERGENCY CARE IN THE UNITED STATES HEALTH SYSTEM

GAIL L. WARDEN (Chair), President Emeritus,

Henry Ford Health System, Detroit, Michigan

STUART H. ALTMAN, Sol C. Chaikin Professor of National Health Policy,

Heller School of Social Policy, Brandeis University, Waltham, Massachusetts

BRENT R. ASPLIN, Associate Professor of Emergency Medicine, University of Minnesota and Department Head,

Regions Hospital Emergency Department, St. Paul

THOMAS F. BABOR, Chair,

Department of Community Medicine and Health Care, University of Connecticut Health Center, Farmington

ROBERT R. BASS, Executive Director,

Maryland Institute for Emergency Medical Services Systems, Baltimore

BENJAMIN K. CHU, Regional President,

Southern California, Kaiser Foundation Health Plan and Hospital, Pasadena

A. BRENT EASTMAN, Chief Medical Officer, N. Paul Whittier Chair of Trauma,

ScrippsHealth, San Diego, California

GEORGE L. FOLTIN, Director, Center for Pediatric Emergency Medicine, Associate Professor of Pediatrics and Emergency Medicine,

New York University School of Medicine, Bellevue Hospital Center, New York

SHIRLEY GAMBLE, Chief Operating Officer,

United Way Capital Area, Austin, Texas

DARRELL J. GASKIN, Associate Professor,

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

ROBERT C. GATES, Project Director,

Medical Services for Indigents, Health Care Agency, Santa Ana, California

MARIANNE GAUSCHE-HILL, Clinical Professor of Medicine and Director,

Prehospital Care, Harbor-UCLA Medical Center, Torrance, California

JOHN D. HALAMKA, Chief Information Officer,

Beth Israel Deaconess Medical Center, Boston, Massachusetts

MARY M. JAGIM,

Internal Consultant for Emergency Preparedness Planning, MeritCare Health System, Fargo, North Dakota

ARTHUR L. KELLERMANN, Professor and Chair, Department of Emergency Medicine and Director,

Center for Injury Control, Emory University School of Medicine, Atlanta, Georgia

WILLIAM N. KELLEY, Professor of Medicine,

Biochemistry & Biophysics, University of Pennsylvania School of Medicine, Philadelphia

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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PETER M. LAYDE, Professor and Interim Director, Health Policy Institute and Co-Director,

Injury Research Center, Medical College of Wisconsin, Milwaukee

EUGENE LITVAK, Professor of Health Care and Operations Management Director,

Program for Management of Variability in Health Care Delivery, Boston University Health Policy Institute, Massachusetts

RICHARD A. ORR, Associate Director, Cardiac Intensive Care Unit, Medical Director, Children’s Hospital Transport Team of Pittsburgh and Professor,

University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pennsylvania

JERRY L. OVERTON, Executive Director,

Richmond Ambulance Authority, Virginia

JOHN E. PRESCOTT, Dean,

West Virginia University School of Medicine, Morgantown

NELS D. SANDDAL, President,

Critical Illness and Trauma Foundation, Bozeman, Montana

C. WILLIAM SCHWAB, Professor of Surgery, Chief,

Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia

MARK D. SMITH, President and CEO,

California Healthcare Foundation, Oakland

DAVID N. SUNDWALL, Executive Director,

Utah Department of Health, Salt Lake City

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

SUBCOMMITTEE ON HOSPITAL-BASED EMERGENCY CARE

BENJAMIN K. CHU (Chair), Regional President,

Southern California, Kaiser Foundation Health Plan and Hospital, Pasadena

STUART H. ALTMAN, Sol C. Chaikin Professor of National Health Policy,

Heller School of Social Policy, Brandeis University, Waltham,Massachusetts

BRENT R. ASPLIN, Associate Professor of Emergency Medicine,

University of Minnesota and Department Head, Regions Hospital Emergency Department, St. Paul

JOHN D. HALAMKA, Chief Information Officer,

Beth Israel Deaconess Medical Center, Boston, Massachusetts

MARY M. JAGIM,

Internal Consultant for Emergency Preparedness Planning, MeritCare Health System, Fargo, North Dakota

KENNETH W. KIZER, President, Chief Executive Officer, and Chairman,

Medsphere Systems Corporation, Aliso Viejo, California

PETER M. LAYDE, Professor and Interim Director, Health Policy Institute and Co-Director,

Injury Research Center, Medical College of Wisconsin, Milwaukee

EUGENE LITVAK, Professor of Health Care and Operations Management Director,

Program for Management of Variability in Health Care Delivery, Boston University Health Policy Institute, Massachusetts

JOHN R. LUMPKIN, Senior Vice President,

The Robert Wood Johnson Foundation, Princeton, New Jersey

W. DANIEL MANZ, Director,

Emergency Medical Services Division, Vermont Department of Health, Burlington

JOHN E. PRESCOTT, Dean,

West Virginia University School of Medicine, Morgantown

C. WILLIAM SCHWAB, Professor of Surgery, Chief,

Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia

JOSEPH L. WRIGHT, Executive Director,

Child Health Advocacy Institute, Children’s National Medical Center;

Professor of Pediatrics,

Emergency Medicine & Community Health, George Washington University Schools of Medicine and Public Health, Washington, District of Columbia; and

State EMS Medical Director for Pediatrics,

Maryland Institute for Emergency Medical Services Systems, Baltimore

Study Staff

ROBERT B. GIFFIN, Study Co-Director and Senior Program Officer

SHARI M. ERICKSON, Study Co-Director and Program Officer

MEGAN MCHUGH, Senior Program Officer

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BENJAMIN WHEATLEY, Program Officer

ANISHA S. DHARSHI, Research Associate

SHEILA J. MADHANI, Program Officer

CANDACE TRENUM, Senior Program Assistant

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:


E. JOHN GALLAGHER, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York

KRISTINE M. GEBBIE, Center for Health Policy, Columbia University School of Nursing, New York, New York

LEWIS R. GOLDFRANK, Department of Emergency Medicine, New York University School of Medicine, New York University Medical Center and Bellevue Hospital Center, New York

JERRIS R. HEDGES, School of Medicine, Oregon Health & Science University, Portland

GARY JOHNSON, Department of Family Medicine, University of Nevada School of Medicine, Reno

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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D. RANDY KUYKENDALL, Emergency Medical and Trauma Services Section, Health Facilities & Emergency Medical Services Division, Colorado Department of Public Health & Environment, Colorado Springs

RONALD V. MAIER, Department of Surgery, Harborview Medical Center, Seattle, Washington

MITCHELL T. RABKIN, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts

SARA ROSENBAUM, Department of Health Policy, School of Public Health and Health Services, The George Washington University Medical Center, Washington, District of Columbia

ALEX B. VALADKA, Department of Neurological Surgery, University of Texas Medical School at Houston


Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Enriqueta C. Bond, Burroughs Wellcome Fund, and Don E. Detmer, American Medical Informatics Association. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

Foreword

The state of emergency care affects every American. When illness or injury strikes, Americans count on the emergency care system to respond with timely and high-quality care. Yet today, the emergency and trauma care that Americans receive can fall short of what they expect and deserve.

Emergency care is a window on health care, revealing both what is right and what is wrong with the care delivery system. Americans increasingly rely on hospital emergency departments because of the skilled specialists and advanced technologies they offer. At the same time, the increasing use of the emergency care system represents failures of the larger health care system—the growing numbers of uninsured Americans, the limited alternatives available in many communities, and the inadequate preventive care and chronic care management received by many. The resulting demands on the system can degrade the quality of emergency care and hinder the ability to provide urgent and lifesaving care to seriously ill and injured patients wherever and whenever they need it.

The Committee on the Future of Emergency Care in the United States Health System, ably chaired by Gail Warden, set out to examine the emergency care system in the United States; explore its strengths, limitations, and future challenges; describe a desired vision of the emergency care system; and recommend strategies required to achieve that vision. Their efforts build on past contributions of the National Academies, including the landmark National Research Council report Accidental Death and Disability: The Neglected Disease of Modern Society in 1966, Injury in America: A Continuing Public Health Problem in 1985, and Emergency Medical Services for Children in 1993.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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The committee’s task in the present study was to examine the full scope of emergency care, from 9-1-1 and medical dispatch to hospital-based emergency and trauma care. The three reports produced by the committee— Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services at the Crossroads, and Emergency Care for Children: Growing Pains—provide three different perspectives on the emergency care system. The series as a whole unites the often fragmented prehospital and hospital-based systems under a common vision for the future of emergency care.

As the committee prepared its reports, federal and state policy makers were turning their attention to the possibility of an avian influenza pandemic. Americans are asking whether we as a nation are prepared for such an event. The emergency care system is on the front lines of surveillance and treatment. The more secure and stable our emergency care system is, the better prepared we will be to handle any possible outbreak. In this light, the recommendations presented in these reports take on increased urgency. The guidance they offer can assist all of the stakeholders in emergency care—the public, policy makers, providers, and educators—to chart the future of emergency care in the United States.


Harvey V. Fineberg, M.D., Ph.D.

President, Institute of Medicine

June 2006

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Preface

Emergency care has made important advances in recent decades: emergency 9-1-1 service now links virtually all ill and injured Americans to immediate medical response; organized trauma systems transport patients to advanced, life-saving care within minutes; and advances in resuscitation and lifesaving procedures yield outcomes unheard of just two decades ago. Yet just under the surface, a growing national crisis in emergency care is brewing. Emergency departments (EDs) are frequently overloaded, with patients sometimes lining hallways and waiting hours and even days to be admitted to inpatient beds. Ambulance diversion, in which overcrowded EDs close their doors to incoming ambulances, has become a common, even daily problem in many cities. Patients with severe trauma or illness are often brought to the ED only to find that the specialists needed to treat them are unavailable. The transport of patients to available emergency care facilities is often fragmented and disorganized, and the quality of emergency medical services (EMS) is highly inconsistent from one town, city, or region to the next. In some areas, the system’s task of dealing with emergencies is compounded by an additional task: providing nonemergent care for many of the 45 million uninsured Americans. Furthermore, the system is ill prepared to handle large-scale emergencies, whether a natural disaster, an influenza pandemic, or an act of terrorism.

This crisis is multifaceted and impacts every aspect of emergency care—from prehospital EMS to hospital-based emergency and trauma care. The American public places its faith in the ability of the emergency care system to respond appropriately whenever and wherever a serious illness

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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or injury occurs. But while the public is largely unaware of the crisis, it is real and growing.

The Institute of Medicine’s Committee on the Future of Emergency Care in the United States Health System was convened in September 2003 to examine the emergency care system in the United States, to create a vision for the future of the system, and to make recommendations for helping the nation achieve that vision. The committee’s findings and recommendations are presented in the three reports in the Future of Emergency Care series:

  • Hospital-Based Emergency Care: At the Breaking Point explores the changing role of the hospital ED and describes the national epidemic of overcrowded EDs and trauma centers. The range of issues addressed includes uncompensated emergency and trauma care, the availability of specialists, medical liability exposure, management of patient flow, hospital disaster preparedness, and support for emergency and trauma research.

  • Emergency Medical Services at the Crossroads describes the development of EMS over the last four decades and the fragmented system that exists today. It explores a range of issues that affect the delivery of prehospital EMS, including communications systems; coordination of the regional flow of patients to hospitals and trauma centers; reimbursement of EMS services; national training and credentialing standards; innovations in triage, treatment, and transport; integration of all components of EMS into disaster preparedness, planning, and response actions; and the lack of clinical evidence to support much of the care that is delivered.

  • Emergency Care for Children: Growing Pains describes the special challenges of emergency care for children and considers the progress that has been made in this area in the 20 years since the establishment of the federal Emergency Medical Services for Children (EMS-C) program. It addresses how issues affecting the emergency care system generally have an even greater impact on the outcomes of critically ill and injured children. The topics addressed include the state of pediatric readiness, pediatric training and standards of care in emergency care, pediatric medication issues, disaster preparedness for children, and pediatric research and data collection.

THE IMPORTANCE AND SCOPE OF EMERGENCY CARE

Each year in the United States approximately 114 million visits to EDs occur, and 16 million of these patients arrive by ambulance. In 2002, 43 percent of all hospital admissions in the United States entered through the ED. The emergency care system deals with an extraordinary range of patients, from febrile infants, to business executives with chest pain, to elderly patients who have fallen.

EDs are an impressive public health success story in terms of access to

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
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care. Americans of all walks of life know where the nearest ED is and understand that it is available 24 hours a day, 7 days a week. Trauma systems also represent an impressive achievement. They are a critical component of the emergency care system since approximately 35 percent of ED visits are injury-related, and injuries are the number one killer of people between the ages of 1 and 44. Yet the development of trauma systems has been inconsistent across states and regions.

In addition to its traditional role of providing urgent and lifesaving care, the emergency care system has become the “safety net of the safety net,” providing primary care services to millions of Americans who are uninsured or otherwise lack access to other community services. Hospital EDs and trauma centers are the only providers required by federal law to accept, evaluate, and stabilize all who present for care, regardless of their ability to pay. An unintended but predictable consequence of this legal duty is a system that is overloaded and underfunded to carry out its mission. This situation can hinder access to emergency care for insured and uninsured alike, and compromise the quality of care provided to all. Further, EDs have become the preferred setting for many patients and an important adjunct to community physicians’ practices. Indeed, the recent growth in ED use has been driven by patients with private health insurance. In addition to these responsibilities, emergency care providers have been tasked with the enormous challenge of preparing for a wide range of emergencies, from bioterrorism to natural disasters and pandemic disease. While balancing all of these tasks is difficult for every organization providing emergency care, it is an even greater challenge for small, rural providers with limited resources.

Improved Emergency Medical Services: A Public Health Imperative

Since the Institute of Medicine (IOM) embarked on this study, concern about a possible avian influenza pandemic has led to worldwide assessment of preparedness for such an event. Reflecting this concern, a national summit on pandemic influenza preparedness was convened by Department of Health and Human Services Secretary Michael O. Leavitt on December 5, 2005, in Washington, D.C., and has been followed by statewide summits throughout the country. At these meetings, many of the deficiencies noted by the IOM’s Committee on the Future of Emergency Care in the United States Health System have been identified as weaknesses in the nation’s ability to respond to large-scale emergency situations, whether disease outbreaks, naturally occurring disasters, or

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

acts of terrorism. During any such event, local hospitals and emergency departments will be on the front lines. Yet of the millions of dollars going into preparedness efforts, a tiny fraction has made its way to medical preparedness, and much of that has focused on one of the least likely threats—bioterrorism. The result is that few hospital and EMS professionals have had even minimal disaster preparedness training; even fewer have access to personal protective equipment; hospitals, many already stretched to the limit, lack the ability to absorb any significant surge in casualties; and supplies of critical hospital equipment, such as decontamination showers, negative pressure rooms, ventilators, and intensive care unit beds, are wholly inadequate. A system struggling to meet the day-to-day needs of the public will not have the capacity to deal with a sustained surge of patients.

FRAMEWORK FOR THIS STUDY

This year marks the fortieth anniversary of the publication of the landmark National Academy of Sciences/National Research Council report Accidental Death and Disability: The Neglected Disease of Modern Society. That report described an epidemic of automobile-related and other injuries, and harshly criticized the deplorable state of trauma care nationwide. The report prompted a public outcry, and stimulated a flood of public and private initiatives to enhance highway safety and improve the medical response to injuries. Efforts included the development of trauma and prehospital EMS systems, creation of the specialty in emergency medicine, and establishment of federal programs to enhance the emergency care infrastructure and build a research base. To many, the 1966 report marked the birth of the modern emergency care system.

Since then, the National Academies and the Institute of Medicine (IOM) have produced a variety of reports examining various aspects of the emergency care system. The 1985 report Injury in America called for expanded research into the epidemiology and treatment of injury, and led to the development of the National Center for Injury Prevention and Control within the Centers for Disease Control and Prevention. The 1993 report Emergency Medical Services for Children exposed the limited capacity of the emergency care system to address the needs of children, and contributed to the expansion of the EMS-C program within the Department of Health and Human Services. It has been 10 years, however, since the IOM examined any aspect of emergency care in depth. Furthermore, no National Academies report has ever examined the full range of issues surrounding emergency care in the United States.

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That is what this committee set out to do. The objectives of the study were to (1) examine the emergency care system in the United States; (2) explore its strengths, limitations, and future challenges; (3) describe a desired vision for the system; and (4) recommend strategies for achieving this vision.

STUDY DESIGN

The IOM Committee on the Future of Emergency Care in the United States Health System was formed in September 2003. In May 2004, the committee was expanded to comprise a main committee of 25 members and three subcommittees. A total of 40 main and subcommittee members, representing a broad range of expertise in health care and public policy, participated in the study. Between 2003 and 2006, the main committee and subcommittees met 19 times; heard public testimony from nearly 60 speakers; commissioned 11 research papers; conducted site visits; and gathered information from hundreds of experts, stakeholder groups, and interested individuals.

The magnitude of the effort reflects the scope and complexity of emergency care itself, which encompasses a broad continuum of services that includes prevention and bystander care; emergency calls to 9-1-1; dispatch of emergency personnel to the scene of injury or illness; triage, treatment, and transport of patients by ambulance and air medical services; hospital-based emergency and trauma care; subspecialty care by on-call specialists; and subsequent inpatient care. Emergency care’s complexity can also be traced to the multiple locations, diverse professionals, and cultural differences that span this continuum of services. EMS, for example, is unlike any other field of medicine—over one-third of its professional workforce consists of volunteers. Further, EMS has one foot in the public safety realm and one foot in medical care, with nearly half of all such services being housed within fire departments. Hospital-based emergency care is also delivered by an extraordinarily diverse staff—emergency physicians, trauma surgeons, critical care specialists, and the many surgical and medical subspecialists who provide services on an on-call basis, as well as specially trained nurses, pharmacists, physician assistants, nurse practitioners, and others.

The division into a main committee and three subcommittees made it possible to break down this enormous effort into several discrete components. At the same time, the committee sought to examine emergency care as a comprehensive system, recognizing the interdependency of its component parts. To this end, the study process was highly integrated. The main committee and three subcommittees were designed to provide for substantial overlap, interaction, and cross-fertilization of expertise. The committee concluded that nothing will change without cooperative and visionary lead-

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ership at many levels and a concerted national effort among the principal stakeholders—federal, state, and local officials; hospital leadership; physicians, nurses, and other clinicians; and the public.

The committee hopes that the reports in the Future of Emergency Care series will stimulate increased attention to and reform of the emergency care system in the United States. I wish to express my appreciation to the members of the committee and subcommittees and the many panelists who provided input at the meetings held for this study, and to the IOM staff for their time, effort, and commitment to the development of these important reports.


Gail L. Warden

Chair

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

Acknowledgments

The Future of Emergency Care series benefited from the contributions of many individuals and organizations. The committee and Institute of Medicine (IOM) staff take this opportunity to recognize and thank those who helped in the development of the reports in the series.

A large number of individuals assembled materials that helped the committee develop the evidence base for its analyses. The committee appreciates the contributions of experts from a variety of organizations and disciplines who gave presentations during committee meetings or authored papers that provided information incorporated into the series of reports. The full list of presenters is provided in Appendix C. Authors of commissioned papers are listed in Appendix D.

Committee members and IOM staff conducted a number of site visits throughout the course of the study to gain a better understanding of certain aspects of the emergency care system. We appreciate the willingness of staff from the following organizations to meet with us and respond to questions: Beth Israel Deaconess Medical Center, Boston Medical Center, Children’s National Medical Center, Grady Memorial Hospital, Johns Hopkins Hospital, Maryland Institute for EMS Services Systems, Maryland State Police Aviation Division, Richmond Ambulance Association, and Washington Hospital Center.

We would also like to express appreciation to the many individuals who shared their expertise and resources on a wide range of issues: Karen Benson-Huck, Linda Fagnani, Carol Haraden, Lenworth Jacobs, Tom Judge, Nadine Levick, Ellen MacKenzie, Dawn Mancuso, Rick Murray, Ed

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. doi: 10.17226/11621.
×

Racht, Dom Ruscio, Carol Spizziri, Caroline Steinberg, Rosemary Stevens, Peter Vicellio, and Mike Williams.

This study received funding from the Josiah Macy, Jr. Foundation, the National Highway Traffic Safety Administration (NHTSA), and three agencies within the Department of Health and Human Services: the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA). We would like to thank the staff from those organizations who provided us with information, documents, and insights throughout the project, including Drew Dawson, Laurie Flaherty, Susan McHenry, Gamunu Wijetunge, and David Bryson of NHTSA; Dan Kavanaugh, Christina Turgel, and David Heppel of HRSA; Robin Weinick and Pam Owens of AHRQ; Rick Hunt and Bob Bailey from CDC’s National Center for Injury Prevention and Control; and many other helpful members of the staffs of those organizations.

Important research and writing contributions were made by Molly Hicks of Keene Mill Consulting, LLC. Karen Boyd, a Christine Mirzayan Science and Technology Fellow of the National Academies, and two student interns, Carla Bezold and Neesha Desai, developed background papers. Also, our thanks to Rona Briere, who edited the reports, and to Alisa Decatur, who prepared them for publication.

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3

 

BUILDING A 21ST-CENTURY EMERGENCY CARE SYSTEM

 

81

   

 The Goal of Coordination,

 

82

   

 The Goal of Regionalization,

 

87

   

 The Goal of Accountability,

 

94

   

 Current Approaches,

 

102

   

 A Proposal for Federal, State, and Local Collaboration through Demonstration Projects,

 

107

   

 Need for System Integration and a Federal Lead Agency,

 

110

   

 Summary of Recommendations,

 

124

4

 

IMPROVING THE EFFICIENCY OF HOSPITAL-BASED EMERGENCY CARE

 

129

   

 The ED in the Context of the Health Care Delivery System,

 

129

   

 Understanding Patient Flow through the Hospital System,

 

131

   

 Impediments to Efficient Patient Flow in the ED,

 

135

   

 Strategies for Optimizing Efficiency,

 

139

   

 Overcoming Barriers to Enhanced Efficiency,

 

152

   

 Summary of Recommendations,

 

160

5

 

TECHNOLOGY AND COMMUNICATIONS

 

165

   

 Information Technology in the Health Care Delivery System,

 

167

   

 Information Technology in the Emergency Department,

 

171

   

 New Clinical Technologies,

 

190

   

 Barriers to the Adoption of Information Technology,

 

194

   

 Prioritizing Investments in Emergency Care Information Technology,

 

200

   

 Summary of Recommendations,

 

202

6

 

THE EMERGENCY CARE WORKFORCE

 

209

   

 Physicians,

 

210

   

 Nurses and Other Critical Providers,

 

229

   

 Enhancing the Supply of Emergency Care Providers,

 

236

   

 Building Core Competencies,

 

238

   

 Addressing the Issue of Provider Safety,

 

240

   

 Increasing Interprofessional Collaboration,

 

243

   

 Addressing the Shortage of Rural Emergency Care Providers,

 

247

   

 Summary of Recommendations,

 

251

7

 

DISASTER PREPAREDNESS

 

259

   

 Defining Disaster,

 

260

   

 Critical Hospital Roles in Disasters,

 

265

   

 Challenges in Rural Areas,

 

281

   

 Federal Funding for Hospital Preparedness,

 

283

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Hospital-Based Emergency Care: At the Breaking Point Get This Book
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Today our emergency care system faces an epidemic of crowded emergency departments, patients boarding in hallways waiting to be admitted, and daily ambulance diversions. Hospital-Based Emergency Care addresses the difficulty of balancing the roles of hospital-based emergency and trauma care, not simply urgent and lifesaving care, but also safety net care for uninsured patients, public health surveillance, disaster preparation, and adjunct care in the face of increasing patient volume and limited resources. This new book considers the multiple aspects to the emergency care system in the United States by exploring its strengths, limitations, and future challenges. The wide range of issues covered includes:

• The role and impact of the emergency department within the larger hospital and health care system.

• Patient flow and information technology.

• Workforce issues across multiple disciplines.

• Patient safety and the quality and efficiency of emergency care services.

• Basic, clinical, and health services research relevant to emergency care.

• Special challenges of emergency care in rural settings.

Hospital-Based Emergency Care is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency care providers, professional organizations, and policy makers looking to address the deficiencies in emergency care systems.

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